Basic Information
| Provider Information | |||||||||
| NPI: | 1386867653 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PASO DEL NORTE CHILDREN'S DEVELOPMENT CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PASO DEL NORTE CHILDREN'S DEVELOPMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 E SCHUSTER AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799024659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155448484 | ||||||||
| FaxNumber: | 9154960751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E SCHUSTER AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799024659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155448484 | ||||||||
| FaxNumber: | 9154960751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARCELEAU | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9155448484 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 610670000 | TX | N | Agencies | Early Intervention Provider Agency | 252Y00000X | 511030000 | TX | N | Agencies | Early Intervention Provider Agency | 261QD1600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 017438501 | 05 | TX | MEDICAID |